Contract Management and Analysis

Transcription

1 Contract management and analysis is one of the most critical focus points. Hospital Financial Managers need a tool to manage, evaluate and optimize reimbursement to achieve the required returns. The PARA Data Editor (PDE) Contracts tab provides the following: 1. Contract tracking for renewals and key terms 2. Settlement of claims by patient type with simple hierarchical tiered payment structure 3. Calculation of Stop Loss impact 4. Calculation of individual claim cap impact loss of reimbursement 5. Comparison of settlement to hospital specific cost data 6. Comparison of settlement to Medicare reimbursement 7. Calculation impact for pro forma what if analysis 8. Calculation of Lower of Charge of DRG or fee schedule loss of reimbursement 9. Denial Tracking and Analysis The Contracts tab is a compont of the PARA Data Editor, a multi function web based revenue cycle management and analysis tool. PARA Healthcare Financial Services Page 1

2 Data Table Requirements The tables required to load the Contract Management system are as follows: 1. Charge Description Master 2. Account Header and Transaction 3. Patient Type and Insurance Crosswalk 4. HIM ICD9 codes for diagnosis and procedures 5. Payer Contracts or matrix Pasted below is a link to the PARA Data Requirements hcfs.com/pde/documents/para_datarequirements.pdf Data Tables are transmitted to PARA using the Secure File Transfer link pasted below hcfs.com/pde/documents/para_filetransferuserguide.pdf PARA tracks all data tables by client and project, with automatic requests to designated Users to refresh the tables. PARA Healthcare Financial Services Page 2

3 Contract Summary Tab The PDE Contract Summary tab page contains the dash board for the Contacts system. The tab contains basic contract notification and settlement terms which apply to all patient types, along with a number of functions: 1. Linking of multiple sibling contracts to a single parent 2. Selection of individual contracts for payment term analysis PARA Healthcare Financial Services Page 3

4 Contract Summary Tab (continued) 3. Sorting of contracts Provides focus and quick retrieval of terms A. Total Charges B. Contract Mnemonic C. Insurance Name 4. Copy terms from one contract to another PARA Healthcare Financial Services Page 4

5 Contract Summary Tab (continued) 5. Reporting There are a number of different reporting options Audit Reports A. Insurance Plan Proof, settlement, claim cap B. Forecasting / Pro Forma Proof and Claim C. Settlement to Cost or Medicare Reimbursement Analysis Proof and Claim D. Settlement to paid claim data / denial reporting EDI 835 records Summary Reports PARA Healthcare Financial Services Page 5

6 Contract Summary Tab (continued) 6. Forecasting / Pro Forma Assignment of a Pro Forma contract to current contract The Forecasting model provides a tool to determine the impact of a change to a contract by quantifying the impact against an historic book of business. Contracting Forecasting / Pro Forma Reporting PARA Healthcare Financial Services Page 6

7 Contract Terms and Settlement Sub Tabs Each of the summary patient types defined on the summary tab link to a sub tab for term construction and settlement, the components of each of the term sub tabs is as follows: 1. Reimbursement Method Define by patient type and contract terms 2. Priority Allows carve outs and exemptions to per diem and DRG 3. Code Type Defines the DRG or fee schedule settlement 4. Code From / To Allows ranges of codes 5. Value Go to payment values, used for per diems 6. NTE Not to exceed, limits percent of charges settlement subject to a per diem cap 7. Claim Cap Limits percent of charges settlement subject to a case cap 8. Type defines APC, HCPCS, DRG PARA Healthcare Financial Services Page 7

8 Inpatient The available terms are as follows: 1. Case Rate based on Diagnosis ICD9 2. Case Rate based on DRG 3. Case Rate based on HCPCS 4. Case Rate based on Procedure ICD9 5. Case Rate Percent of Charges based on DRG 6. DRG Medicare Weight 7. DRG Medicare Weight Insurance Per Diem 8. DRG Special Weight 9. Per Diem 10. Per Diem based on Procedure ICD9 11. Per Diem based on Rev Code 12. Per Diem Lower of Percent Discount or Daily Limit 13. Percent of Charges 14. Percent of Charges subject to Claim Limit 15. Cost Subject to Settlement PARA Healthcare Financial Services Page 8

9 Outpatient The available terms are as follows: 1. Fee schedule Contract Specific 2. Fee schedule Cost Plus 3. Fee schedule Lab Medicare 4. Fee schedule multi code discount 100%, 50% 5. Fee schedule multi code discount 100%, 50%, 25% 6. Fee Schedule Percent of Charge 7. Fee schedule Percent of Invoice 8. Fee schedule Pro Fee Medicare 9. Percent of Charges 10. Percent of Charges not subject to Fee Schedule 11. Percent of Charges subject to Claim Limit 12. Per Visit Based on Fee Schedule PARA Healthcare Financial Services Page 9

10 Ambulatory Surgical The available terms are as follows: 1. ASC Contract Specific 2. ASC Medicare 3. ASC Groups ASC Fee Schedule 5. ASC Percentage of Charge 6. Fee schedule Contract Specific 7. Fee schedule Cost Plus 8. Fee schedule Lab Medicare 9. Fee schedule multi code discount 100%, 50% 10. Fee schedule multi code discount 100%, 50%, 25% 11. Fee Schedule Percent of Charge 12. Fee schedule Percent of Invoice 13. Fee schedule Pro Fee Medicare 14. Percent of Charges 15. Percent of Charges not subject to Fee Schedule 16. Percent of Charges subject to Claim Limit 17. Per Visit Based on Fee Schedule PARA Healthcare Financial Services Page 10

11 Emergency The available terms are as follows: 1. Fee schedule Contract Specific 2. Fee schedule Cost Plus 3. Fee schedule Lab Medicare 4. Fee schedule multi code discount 100%, 50% 5. Fee schedule multi code discount 100%, 50%, 25% 6. Fee Schedule Percent of Charge 7. Fee schedule Percent of Invoice 8. Fee schedule Pro Fee Medicare 9. Percent of Charges 10. Percent of Charges not subject to Fee Schedule 11. Percent of Charges subject to Claim Limit 12. Per Visit Based on Fee Schedule PARA Healthcare Financial Services Page 11

12 Urgent Care The available terms are as follows: 1. Fee schedule Contract Specific 2. Fee schedule Cost Plus 3. Fee schedule Lab Medicare 4. Fee schedule multi code discount 100%, 50% 5. Fee schedule multi code discount 100%, 50%, 25% 6. Fee Schedule Percent of Charge 7. Fee schedule Percent of Invoice 8. Fee schedule Pro Fee Medicare 9. Percent of Charges 10. Percent of Charges not subject to Fee Schedule 11. Percent of Charges subject to Claim Limit 12. Per Visit Based on Fee Schedule PARA Healthcare Financial Services Page 12

13 Non Patient The available terms are as follows: 1. Fee schedule Contract Specific 2. Fee schedule Cost Plus 3. Fee schedule Lab Medicare 4. Fee schedule multi code discount 100%, 50% 5. Fee schedule multi code discount 100%, 50%, 25% 6. Fee Schedule Percent of Charge 7. Fee schedule Percent of Invoice 8. Fee schedule Pro Fee Medicare PARA Healthcare Financial Services Page 13

14 Stop Loss The stop loss term settlement components are as follows: 1. Start / End Dates Used to define multiple periods 2. Dollar Threshold Value 3. Threshold Type Dollar or per diem 4. Percentage of Billed Charges settlement percentage 5. Method 1 st or 2 nd dollar, per diem 6. Dollars Not to Exceed Value 7. Not to Exceed Type Per Diem or case 8. Not to Exceed Quantity Multiplier of per diem or case reimbursement 9. Exclusions Implants, trauma, high cost drugs 10. Exclusion Definition All claims or specific DRG s 11. Exclusion Codes Value PARA Healthcare Financial Services Page 14

15 Blended Rate Allows multiple blended rates to be used for extended settlement period Comments / Notes Allows all Users to note and view terms and communications PARA Healthcare Financial Services Page 15

16 Contacts Provides all Users a central point to record names, phone numbers and addresses ADDB Provides the User an Excel worksheet file to record in a central file all fee schedules by patient type PARA Healthcare Financial Services Page 16

17 The Contract Management system is also used is for the Quote a Price and the Pricing tabs. Quote a Price Patient Price Quote, Coverage and Eligibility Checker Pricing Market based pricing to competitively position the hospital PARA Healthcare Financial Services Page 17